Impact Assessment

Introduction

In public health, Health Impact Assessments are a combination of procedures, methods and tools which are used to evaluate the health effects of a programme, project, or policy.

These include qualitative, quantitative and participatory techniques which generate recommendations that will help the project implementer, decision- and policy-makers and/or other stakeholders make choices about whether to make any modifications to the programme.

They can also inform decision-makers and partners on whether (and how) the programme can be scaled up. To read a Health Impact Assessment conducted on a Safe Routes to Schools progamme in the United Kingdom click here.

Every child deserves a safe and healthy journey to school. It is a fundamental right. And yet, every four minutes a child is lost on our roads. Millions more are injured in road traffic crashes or their lungs are damaged by the effects of urban outdoor air pollution. Addressing road traffic is complex and dangerous, and children are especially vulnerable.

Many children do not have the option to walk or cycle to school because it is too unsafe. There are no footpaths, roads don’t have lights, or vehicle speeds are too high for them to reach their school, their education, their future, safely and in comfort.

Focusing on schools as an intervention site for road safety has far-reaching effects, not just on students, but on whole communities and ultimately cities. Simple evidence-based interventions, such as those in this toolkit, prevent deaths and injuries from not only dangerous roads and polluted air, but also through the cumulative positive effects of walking and cycling on physical activity, ultimately reducing noncommunicable diseases. Promoting this approach is a key policy objective for Child Health Initiative, comprising key international agencies, donors and research partners.

More than 500 children die on the world’s roads every day, almost half of them as pedestrians, cyclists and motorcyclists. For their parents, siblings and extended families, there are life-long social and financial consequences, but the pain and suffering that they endure cannot be quantified. Most of these children are from less-resourced settings already struggling with triple burdens – communicable, noncommunicable diseases and injuries.

Prasad's story

On 26 December 1996, Prasad left home early in the morning to go to school. He only ate one chapati before leaving, assuring his mother that he would eat more when he returned. Before he left, he asked his sister for some money to buy a greeting card for her soon to be husband. He cycled to school safely that morning, but never made it back. A speeding tanker lorry hit him, throwing him off his bicycle and into the road. He sustained a head injury and lost consciousness. The driver tried to escape – he had previously killed two people in crashes. Two college student witnesses chased him down and brought him to the police, before returning to the scene to search Prasad’s schoolbag and find out what school he attended. They contacted the principal, who took the unconscious boy to the hospital.

The students found his parents and delivered the tragic news. By nightfall, Prasad’s parents went to the hospital to see him lying unconscious in a hospital bed. The doctors said they did not know if Prasad would live. The next day, his condition deteriorated and he was hooked up to an oxygen tank.

Towards the evening, Prasad took his last breath. He would no longer eat the chapattis his family prepared for him. He would not post the greeting card to his soon to be brother in law. His family said that his name was misprinted in the newspaper as Prakash (light), but his death plunged them further into gloom and darkness.

The World Bank estimates crashes to cost as much as 7% of a country’s Gross Domestic Product in some regions, and a global economic loss of close to 2 trillion dollars every year. Despite high level policy instruments and global leadership, there has been little action.

The tide may be turning. Recently, World Bank President Dr Jim Kim called for more attention to air pollution and transportation as part of a Human Capital approach emphasising education and health services above infrastructure investment. He wrote “Countries with large gaps in human capital need to radically rethink how they are preparing their people for what lies ahead. Countries need a range of investments that improve outcomes, including clean air and water, safe transportation to get children to school, health clinics, and social protection to ensure that no one is left behind.” This approach, with policies that put people first, is fully endorsed by the Child Health Initiative.

The UN’s ‘Every Women, Every Child’ (EWEC) initiative, launched in 2010, aims to provide a framework and roadmap for efforts to end preventable deaths among women, children, and adolescents. Its Global Strategy for the SDGs, published in 2015, builds on the focus and achievements of the Millennium Development Goals with an emphasis on continuing collaborative responses to tackle leading killers of expectant mothers, newborns and the under-fives, as well as HIV/AIDS, Malaria, Tuberculosis and neglected tropical diseases.

This vision has succeeded in marshalling funding pledges for the EWEC Global Strategy of at least US$ 28.4 billion, with lower-middle-income countries pledging an estimated US$ 8.5 billion of the total. The Global Financing Facility in Support of Every Woman, Every Child100, launched at the 2015 Addis Ababa Financing for Development Conference, plays a coordinating role, helping governments to focus strategies, find donor and implementation partners and design reforms of domestic health financing.

Yet little of this funding and effort has been allocated to improving air quality, indoor or outdoor, and none to tackling the leading killer of adolescents: road traffic injury.

According to a recent study on the case for investing in adolescent health in the Lancet, “an investment of less than $1·0 per capita each year in the prevention of road traffic injury would reduce deaths and serious disability by about 30%”. It went on to show that for interventions targeting road traffic injuries, a benefit-cost ratio of 5·9 (95% CI 5·8–6·0) was achieved on investments of just $0·6 per capita each year.

In Tanzania for example, Amend, with support from the FIA Foundation, demonstrated that focusing relatively low cost infrastructure improvements on schools with the highest road traffic injury rates prevents one road traffic injury for every 286 at-risk children, reducing injury rates by at least a quarter, and serious head injuries by half.

Further evidence that investing in road safety makes good economic sense comes from the World Bank. According to their new report, road traffic crashes are the single largest cause of death among young people (15-29 years) and halving their death and injury rate could lead to long-term GDP increases of up to 22% in some countries. The President of the World Bank, Dr Jim Yong Kim, encouraged action at all levels to address the issue.

Private sector and philanthropic support for civil society is vital to develop and sustain advocacy voices within countries and across the region, and to support the demonstration projects which provide the evidence to fuel larger scale investment.

This strong evidence has led donors like Michael Bloomberg to invest $259 million over the last 12 years to implement proven interventions in some LMICs. The Bloomberg Philanthropies Initiative for Global Road Safety, while not focusing specifically on children and adolescents, implements five proven interventions to reduce child injuries:

Changing behaviours

Improving infrastructure

Promoting sustainable urban transport

Improving vehicle standards

Strengthening policies

The Fondation Botnar has also been led by the evidence to invest in child and adolescent health, by recently announcing the Botnar Challenge, led by the Global Road Safety Partnership. The Challenge supports road safety projects from consortiums representing partners from government, civil society and the private sector impact children in India, Mexico, Romania, South Africa, Tunisia and Vietnam.

According to the UNECE Executive Secretary, Olga Algeyerova, “Transforming the global road safety situation, which represents 1.25 million deaths and an estimated economic cost of $1.85 trillion every year, urgently requires the strengthened involvement of a wide range of partners and the enhanced coordination of global efforts”. As she launched the UN Road Safety Trust Fund in August 2018, she said the fund was another important step in the right direction.

These are positive examples of the contribution being made by donors. But significantly more funding is needed, from private sector, philanthropic and bilateral sources if civil society is to be sufficiently strengthened to meet the challenge of the Sustainable Development Goals.

The Child Health Initiative was launched in 2016 because nobody in the corridors of power was fighting for children’s rights to mobility. We’ve embraced the “Nothing about us without us” ethos by listening to children and young adults, meeting them in their streets and their schools, working with them to develop new advocacy tools to demand safe streets and clean air.

When developing a strategy for a safe journey to school in your city, it is important to understand the risks that may be found around schools. These are some of the common risks that should be taken into account:

Inadequate or poorly designed drop off/parking zones leading to conflict between cars & pedestriansLack of sidewalks, pathways, cycle pathsSchool may be on opposite side of a busy highwaySchool may be hidden from drivers view (esp rural schools)

Road users

Lack of (or inadequate) school policyDrivers not obeying road rules, e.g. speeding, overtaking, etcDrivers not paying attention to children around schoolChildren not crossing at designated siteNo supervision of children

Bus safety

Motorists passing a stationary bus with children getting on and offMotorists not obeying speed limitsUnsafe pedestrian activity to and from school busesBuses stopping at unsafe locations

As you develop your strategy for a safe journey to school in your city, bear in mind these 10 evidence-based interventions which we know will keep children safe on their route to school whether they are walking, cycling or being transported in a vehicle.

Your strategy should embrace the safe systems approach – it should not just focus on the child as a road user – and it should include a door-to-door experience for the school child, not just focusing on the school area alone.

Ask yourself the following questions:

Road Users:

What initiatives can improve the road behaviour of parents, teachers and children?

In 2010, Vietnam passed legislation explicitly mandating child helmet use for children aged six years and older. One year later, only 18% of children in Hanoi, Danang, and Ho Chi Minh City were wearing helmets on motorcycles. Why?

To address the problem, the Asia Injury Prevention Foundation designed and implemented a comprehensive advocacy campaign to increase helmet wearing rates and protect children by improving enforcement. Throughout the campaign, ongoing research, monitoring, and evaluation was conducted, so that it could be tweaked accordingly along the way.

The campaign was developed using quantitative and qualitative methods. Researchers from Vietnam National University conducted an in-depth baseline study to identify factors that affect child helmet wearing rates, including motivations and barriers to wearing a helmet, the road safety environment, and other social factors. They conducted school observations in randomly selected districts in three major cities. The rates served as the baseline wearing rates against which the campaign's efficacy was measured at the end of the project. In addition to helmet use observations, the research team also conducted interviews and focus groups with parents, teachers, school administrators, and students to better understand why child helmets were or were not being used. These key findings were used to develop a campaign strategy and to design and set targets for the project.

Engagement with the police and other authorities was essential. Meetings and workshops with police revealed that a lack of human resources and competing financial priorities were a key reason for the lack of enforcement of child helmet use. Other reasons included the social difficulty of giving fines to parents when the child helmet law was so unpopular, coupled with children becoming distressed (about being late) if they were fined on their way to school. Realizing how effective police enforcement was in raising the adult helmet wearing rate, the AIP Foundation and partners concluded that enhanced police enforcement, alongside better in-school enforcement and policies, would be a necessary and complementary component of the child helmet campaign.

In addition to the baseline study, AIP Foundation and partners conducted ongoing monitoring, evaluation, and research throughout each of the three phases of the integrated campaign. Through a pilot approach, each campaign component was implemented on a small scale in one phase, evaluated and adjusted, then scaled up in the following phase. For example, enhanced police enforcement was piloted in select districts of Ho Chi Minh City during phase one, before scaling up to all three target cities in phase two. This enabled the advocacy campaign to present results of success in enforcement activities as a rationale for a further scaled-up response.

Implementing the police enforcement component of the campaign provided valuable insight to campaign partners. Importantly, campaign partners noticed that targeting specific districts had positive spillover effects into other districts. Enhanced police enforcement was conducted in pre-selected areas in the target cities, but the coordination of the police forces at the district and provincial level made it possible for other districts and provinces to learn about and implement the campaign's successful enforcement strategies.

The most critical component of the campaign, in terms of long-term impact, was the commitment to building a strong network of road safety partners in Vietnam to support and sustain the child helmet campaign. These partners – which now include multiple government agencies, NGOs, international organizations, research bodies, and private sector organizations – brought a diverse range of resources, skills, and perspectives to the campaign. By the final phase of the campaign, the partnership was committed to continuing the campaign components in the target cities, in addition to expanding the campaign to other provinces in Vietnam.

The campaign team focused on four key indicators to determine the success of the public awareness campaign (PAC): campaign exposure, knowledge change, attitude change, and behaviour change.

Campaign exposure was measured by assessing the extent to which the target groups (namely, parents, students, and members of the school community) saw and recalled the key messages of the PAC materials. For example, the PAC evaluation measured how many parents remembered the campaign message that “Children also need a helmet.” Knowledge change was the first component: the public awareness campaign measured by assessing the increase in awareness among parents and adult supervisors about the mandatory child helmet law. Attitude change was measured by assessing the perceived value of child helmets, and behaviour change was measured through direct observation of child helmet wearing rates in the target cities (noting that police and school enforcement also played a role in behaviour change).

Other measurements of success were also used to help the campaign team and partners evaluate and adjust the PAC throughout the three phases. The PAC incorporated a variety of communication activities, including direct communication to the target group, mass media communication, and digital media communication, all focused on promoting child helmet use.

Distribution of educational materials to primary students and parents such as notebooks and hand fans that addressed the child helmet myths uncovered in the baseline study. These materials also provided information about the child helmet law and reminders to wear a helmet.

Interactive informational sessions at schools for students, parents, and the school community in the target cities.

Letters to parents asking for their commitment to always put a helmet on their children.

Audio broadcasts at school gates aired during school dismissal hours to remind students and parents to wear a helmet on a motorcycle.

These direct communication activities served to emphasize the campaign’s key messages to students, teachers, school administrators, and parents. In addition, direct incentives were provided to the target group, such as the provision of free helmets to select students and the distribution of helmet discount vouchers redeemable at high-quality helmet shops, to further encourage child helmet use.

The evaluation of the PAC showed positive and encouraging results. Of people surveyed at the end of the third phase of the campaign, 94 percent of respondents across Hanoi, Danang, and Ho Chi Minh City reported having heard about or seen components of the PAC. Among those exposed to the campaign in the three target cities, 88% recalled the campaign’s key message: “Children also need a helmet.” Among those surveyed in the target cities, 96% believed that it is necessary for children to wear a helmet when on a motorcycle, compared to only 87% in the baseline. Further, the number of respondents who believe that a helmet is actually harmful for a child reduced from 33% in the baseline study to 10% by the end of phase three.

In defining the most effective channels for campaign communications, the campaign team found a mix of media to be most effective, from billboards through to TV and radio, and social media. Social media was found to be effective, in reaching a wide audience. Social media outlets including Facebook, Twitter, and others proved highly complementary in spreading the campaign messages to thousands of parents throughout the target areas and beyond, at minimal cost. For example, the campaign’s “Children also need a helmet” Facebook page received more than 34,000 followers, and nearly 10,000 parents signed an online pledge to always put a helmet on their child.